Chapter 4
Section 5.6
Breast
Reconstruction As A Result Of A Congenital Anomaly
Issue Date: April 16, 1986
Copyright: CPT only © 2006 American Medical
Association (or such other date of publication of CPT).
All Rights Reserved.
Revision:
1.0 CPT PROCEDURE CODES
19361 - 19369, 19499
2.0 DESCRIPTION
A congenital anomaly is a significant
deviation from the normal form, existing at, and usually before,
birth. It also refers to certain malformations or diseases which
may be either hereditary or due to some influence occurring during
gestation.
3.0 POLICY
3.1 Breast
reconstructive surgery, to include surgery performed to establish
symmetry, is covered to correct breast deformities related to a
verified congenital anomaly. The following are examples of congenital
anomalies that require breast reconstruction:
3.1.1 Amastia
(absence of the breast); athelia (absence of nipple); polymastia
(supernumerary breasts); polythelia (supernumerary nipples); tubular
breast deformity; Poland syndrome.
3.1.2 Congenital
hypoplasia of one breast and gigantomastia of the contralateral
breast, if the breast reduction meets medical necessity criteria
outlined in
Section 5.4.
3.1.3 Paucity
of breast tissue due to chest wall deformities.
Note: The intent of the law is to
allow coverage for reconstructive surgery to correct a congenital anomaly.
A congenital anomaly may be present at birth, but only manifest
later; e.g., at puberty. In these cases, documentation (i.e., photographs
and physical examination, etc.) to verify the anomaly may be required.
3.2 Augmentation and/or reduction
of the collateral breast to correct congenital asymmetry when related
to a congenital anomaly is covered.
3.3 Breast
Magnetic Resonance Imaging (MRI) to detect implant rupture is covered.
The implantation of the breast implants must have been covered by
TRICARE.
4.0 EXCLUSION
Reconstructive breast surgery
for incomplete or underdevelopment of breast not related to a verified
congenital anomaly may not be cost-shared.
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